Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Diffusion Tensor Imaging Technique Delineating the Prognosis for Cerebellar Mutism in Posterior Fossa Tumors: A New Tool

AIM

Cerebellar mutism syndrome (CMS) is a morbid complication of posterior fossa surgery in children. This review focuses on the current understanding of pathophysiology in the white matter tracts (WMT) using diffusion tensor imaging (DTI).

MATERIAL AND METHODS

A series of 38 patients operated on for posterior fossa tumors in our institute between December 2019 till May 2021 were evaluated neurologically along with characteristics of mutism and DTI imaging (fractional anisotropy) in preoperative and postoperative periods. We also noted tumor size, location, volume, brainstem compression, cerebellar peduncle involvement, extent of resection, surgical approach, and histopathology.

RESULT

Cerebellar mutism developed in five patients. The mean age, male sex, tumor size >5 cm, superior cerebellar peduncle involvement, and vermian incision were found to have positive correlation with the development of CMS. They showed reduction in fractional anisotropy in superior cerebellar peduncle (SCP) following resection; however, others' WMT did not show any significant change in fractional anisotropy values pre- or post-surgery.

CONCLUSION

Our study suggests that functional disruption of WMT, i.e., superior cerebellar peduncle and dentato-thalamo-cortical tract (DTC) is the underlying pathophysiological component of CMS. Taking this into consideration, we need to deploy techniques to limit the damage to the superior cerebellar peduncle and DTC using neurophysiological monitoring.

Use of Artificial Intelligence for the Development of Predictive Model to Help in Decision-Making for Patients with Degenerative Lumbar Spine Disease

Context  The aim of the study was to develop a prognostic model using artificial intelligence for patients undergoing lumbar spine surgery for degenerative spine disease for change in pain, functional status, and patient satisfaction based on preoperative variables included in following categories—sociodemographic, clinical, and radiological.

Methods and Materials  A prospective cohort of 180 patients with lumbar degenerative spine disease was included and divided into three classes of management—conservative, decompressive surgery, and decompression with fixation. Preoperative variables, change in outcome measures (visual analog scale—VAS, Modified Oswestry Disability Index—MODI, and Neurogenic Claudication Outcome Score—NCOS), and type of management were assessed using Machine Learning models. These were used for creating a predictive tool for deciding the type of management that a patient should undergo to achieve the best results. Multivariate logistic regression was also used to identify prognostic factors of significance.

Results  The area under the curve (AUC) was calculated from the receiver-operating characteristic (ROC) analysis to evaluate the discrimination capability of various machine learning models. Random Forest Classifier gave the best ROC-AUC score in all three classes (0.863 for VAS, 0.831 for MODI, and 0.869 for NCOS), and the macroaverage AUC score was found to be 0.842 suggesting moderate discriminatory power. A graphical user interface (GUI) tool was built using the machine learning algorithm thus defined to take input details of patients and predict change in outcome measures.

Conclusion  This study demonstrates that machine learning can be used as a tool to help tailor the decision-making process for a patient to achieve the best outcome. The GUI tool helps to incorporate the study results into active decision-making.

Intraoperative Squash Smear in Central Nervous System Tumors and Its Correlation with Histopathology: 1 Year Study at a Tertiary Care Centre

Background:

Intraoperative squash smear cytology is a simple and reliable technique for rapid intraoperative diagnosis of neurosurgical specimens. The study was designed to assess the accuracy of intraoperative squash smear in the diagnosis of central nervous system (CNS) space-occupying lesions.

Materials and Methods:

One hundred and fifty cases of CNS space-occupying lesion were studied in a period of 15 months. Smears were prepared from the biopsy sample obtained at the time of operation and were stained with rapid hematoxylin and eosin method.

Results:

One hundred and forty-one cases showed complete correlation with histopathology, two cases showed partial correlation, and seven cases were discrepant. The overall diagnostic accuracy was found to be 94%.

Conclusion:

Intraoperative squash smear thus provides diagnosis with fair accuracy in brain tumors and is of great value in intraoperative consultation.

Isolated fourth ventricle haemorrhage: “think beyond intracranial source’’ unusual presentation of lumbosacral spine arteriovenous malformation presentation

Spinal arteriovenous malformations (SAVMs) are rare vascular lesions and account for about 4% of primary intraspinal masses. Since SAVMs can involve any location along the spinal column and produce a host of different problems, the symptoms are extremely variable. There are few reports of simultaneous cerebral SAH and intraventricular hemorrhage (IVH) following rupture of a spinal AVM (SAVMs). Herein, we present a rare case of Lumbo Sacral spine arteriovenous malformation, which clinically manifests as sudden onset of severe headache and vomiting due to isolated fourth ventricle Hemorrhage (IVH) without cerebral subarachnoid hemorrhage.

Role of Diffusion-weighted Imaging in Detecting Early Ischemic Brain Injury Following Aneurysmal Subarachnoid Hemorrhage

Background:

Aneurysmal SAH is the significant cause of morbidity and mortality in stroke patients. Early brain injury and delayed cerebral ischemia are the two main responsible pathophysiologic processes. Cerebral ischemia needs to be detected early so that early aggressive therapy could be started. Although Diffusion weighted imaging (DWI) has often been utilized for the measurement of acute ischemic strokes, its role in the detection of early cerebral ischemia due to aneurysmal subarachnoid hemorrhage has not been extensively investigated. This study is being carried out to describe the role of DWI in detecting early ischemic brain injury and outcome after aneurysmal SAH.

Aim:

Efficacy of DWI in detecting ischemic injury and predicting outcome after aneurysmal SAH.

Material and Methods:

In this prospective study 44 consecutive patients who had aneurysmal SAH; admitted within 7 days of their ictus were included. Hunt and Hess grade on admission and modified Fisher grade of SAH were noted. Plain CT brain and MR DWI was done on day before surgery. Diffusion restriction on DWI was correlated with postoperative neurological deficit, postoperative CT finding and outcome of the patient at 1 month follow-up.

Results:

DWI revealed restricted diffusion in 12 patients, out of which 1 patient was having infarction in preoperative CT scan, 6 patients were having postoperative deficit in the form of disorientation, hemiparesis and aphasia, and all patients were having infarction in postoperative CT scan. When DWI findings were compared on the basis of postoperative neurological deficit, postoperative CT finding and modified Rankin outcome score at 1month follow-up, results were statistically significant.

Conclusion:

DWI shows cerebral ischemia much earlier than CT scan in cases of aneurysmal SAH. It has significant correlation with postoperative neurological status and outcome of the patient.

Increasing the safety of surgical treatment for complex Cranio-vertebral anomalies using customized 3D printed models

Surgery for the Cranio-vertebral (CV) junction anomalies using top loading subocciput (C0)/C1-C2 screws is difficult and requires high level of skill and expertise. This is because of complex abnormal anatomy in that region and other issues including the instrumentation. Thorough knowledge of the 3D anatomy of the Craniovertebral junction of the patient is essential for favourable outcome. The customised 3D printed model of CV junction region of the patient can be used for studying the anatomy and relationship of vertebral artery to the C1-C2 joint before the actual surgery. Thirteen patients (includes twelve males and one female) of congenital CV junction anomalies having AAD with or without BI (Basilar Invagination) were included in the study. For all thirteen patients, customised 3D models of CV junction were made based on their CT scan data. The rehearsal of surgical procedure on the model was done a day before the actual surgery. Post surgery, twelve out of thirteen patients showed significant clinical and radiological improvement. We did not had any misplaced screws or vertebral artery injury. 3D models can improve decision making and planning of the surgical procedure in the CV junction region. It unmasks abnormal bony & vascular anatomy effectively. Moreover the rehearsal of the surgical procedure enables the surgical team to be more confident & familiar with the anatomy during the actual surgery.

A rare case of dural arteriovenous fistula presenting as primary intraventricular hemorrhage

Primary intraventricular haemorrhage (PIVH) is rare. Dural arteriovenous fistula causing PIVH is extremely rare. We report a case of a 17 year old boy who presented with left hemiparesis, left lower motor neuron facial palsy and ataxia. His computed tomography head revealed primary intraventricular hemorrhage. Catheter super selective angiography revealed a dural arterio venous fistula with arterial feeder arising from the middle meningeal artery as well as from the inferior marginal tentorial artery. Glue injection led to successful disappearance of the fistula and eventual clinical recovery.

Geriatric head injuries - Experience and expectations

It is widely known that global citizenry is continuing to age. The elderly head trauma patients, comprising 4.83% in our series are important from neurosurgical aspects. We conducted a study of elderly head injury patients admitted to our unit in last 11 years. Out of 620 patients, 423 males and 197 female, constituting a ratio of 2.1∶1. Fall constitutes the principle mode of injury (56.29%) followed by RTA (44.1%). We analyzed all the cases for surgical intervention after careful assessment of neurological condition. Amongst all cases operated for acute trauma, good recovery was seen in 51.8% and mortality in 41.7%, whereas in chronic subdural haematoma 84.2% cases showed good recovery as against mortality in 10.5%. In our society, due to very close family ties and desperation of family members to try active intervention even in patients with expected bleak outcome, we operated a fairly large number of cases and concluded that outcome was better after operative intervention.

Intraventricular racemose type neurocysticercosis with anterior interhemispheric fissure cyst: A rare case report

Racemose type of neurocysticercosis (NCC) is a rare form of parasitic infestation of central nervous system. Most commonly it is found in fourth ventricle and cisterns. On reviewing the PubMed and Google databases, we found that this would be the first reported case of racemose type NCC in occipital horn of lateral ventricle with obstructive hydrocephalus, along with an incidental interhemispheric fissure arachnoid cyst.

Giant cell glioblastoma in a child: A rare case report

Giant cell glioblastoma (GCG) is a subtype of Glioblastoma multiforme that is rare in incidence and distinct in features and histopathological examination. It is reported to have better prognosis than common glioblastomas. The incidence of GCG in children is even more rare. We report a case of GCG in a 10-year-old boy along with a review of the relevant literature focusing on the differentiating points from common glioblastoma.

Mucocele of the sphenoid sinus: A rare cause of reversible 3(rd) nerve palsy

Ophthalmoplegia due to 3^rd nerve palsy is a common occurrence, and is usually a sign of diabetes mellitus or a serious intracranial disease. We report a rare case of pupil sparing 3^rd nerve palsy caused by mucocele of the sphenoid sinus. The patient regained 3^rd nerve functions after successful decompression of the mucocele. Early and correct diagnosis of this relatively benign condition is important to prevent permanent neurological deficits, including visual loss by optic nerve atrophy. Etiology, clinical manifestations and treatment of the sphenoid mucoceles is discussed and available literature is reviewed.

Intracranial metastasis of spinal intramedullary anaplastic astrocytoma

Meningeal spread of spinal intramedullary astrocytoma into the cranium is rare. Only few case reports are available so far in the literature. We report a case of intramedullary high grade astrocytoma of the conus, developing intracranial metastasis after three months of partial excision of the spinal mass. The need for radical surgery, entire neuroaxis radiation, and adjuvant chemotherapy is suggested in the management of malignant spinal cord astrocytoma to prevent dissemination.

Low velocity penetrating head injury with impacted foreign bodies in situ

Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

The human tail: rare lesion with occult spinal dysraphism--a case report

Human tail or tail-like caudal cutaneous appendage is a rare fingerlike, midline protrusion at the lumbosacrococcygeal region, often associated with occult spinal dysraphism. A 2-month-old male child presented here had a lumbosacral tail-like appendage with underlying spinal dysraphism without any appreciable neurological deficit. In contradiction to a previous report, true vestigial tails are not benign because they may be associated with underlying dysraphic state. About 50% of the cases were associated with either meningocele or spina bifida occulta. Management of such lesions must include complete neurological history and examination as well as magnetic resonance or computed tomographic imaging. After diagnosis, microsurgery should be performed if there is any intraspinal component to avoid any damage and neurological deficit.

Aneurysmal bone cyst of the temporal bone: a case report

Aneurysmal bone cyst in temporal region is rare. It is a benign condition and may extend intracranially. Total surgical removal is recommended, whenever possible in one stage or in multiple stages. Prognosis is excellent and total removal will effect a cure. An unusual case of aneurysmal bone cyst of temporal region is reported.

Meningioma associated with contralateral chronic subdural haematoma: a short report

Two unusual cases of meningiomas associated with opposite chronic subdural haematoma are presented.

Congenital intracranial teratoma of the lateral ventricle

A case of lateral ventricular teratoma in neonate, where near total excision of tumour was done, is being reported with the review of literature.

Dermatofibrosarcoma protuberans of scalp : a case report

A case of dermatofibrosarcoma protuberans of scalp involving the underlying bone, operated after recurrence by taking safety margin of 3 cm and skin deficit covered by transposition flap, is being reported. Modality of treatment has been discussed.